By Annie Holcombe

Generalised Anxiety disorder, also known as GAD, can be difficult to diagnose. The signs and symptoms of GAD are common to many people, we all worry about things , and most people have at some time or another found that worry can be hard to control. {Morrison, 1995}
Anxiety is an inevitable part of our life in modern society, we meet daily situations where it is appropriate and reasonable to react with some anxiety, if we didn’t feel any anxiety at all in response to everyday challenges involving potential loss or failure, something would be wrong. We all have our ways of dealing with our anxieties, helping us to remain or regain balance and keep things in perspective. {Bourne,1995,pg 4}
People who suffer generalised anxiety disorder, GAD, have certain symptoms that persist more often than not for a period of 6 months or longer. Criteria for diagnosing certain anxiety disorders have been established and are listed in a manual known as the DSM1V{ Diagnostic and statistical manual of mental disorders} The following description of signs and symptoms are based on this criteria
SIGNS AND SYMPTOMS
# Chronic, or excessive anxiety and worry that persists for a majority of days during a 6 month period. The anxiety is about several events or activities. {Eg finances, relationships, health, work performance}.
It is common for GAD clients to have a large number of worries, and to spend a lot of time worrying
To be given a diagnosis of generalised anxiety disorder, the client experiences excessive worry, that is not accompanied by panic attacks, phobias or obsessions.
#The client has difficulty controlling these feelings, and the intensity or frequency of the anxiety is out of proportion to the actual likelihood of the feared event happening.
#Additionally, GAD disorders involve having at least three of the following six symptoms {Symptoms present more days than not over the past 6 months
*Restlessness – feeling keyed up, edgy
*Being easily fatigued,
* Difficulty concentrating
* Irritability
* Increased muscle tension
* Difficulties with sleep
The symptoms experienced cause significant distress and/or interfere with your ability to function at occupationally, socially or in other important areas.
The disorder is not directly caused by a medical condition {hyperventilation, thyroid problems}, or by use of a substance or medication.
# GAD often occurs together with depression, a competent therapist can usually distinguish which disorder is primary, in some cases the distinction is difficult.
#GAD can develop at any age, in children and teenagers, the worry tends to be over school or sports performance. In Adults the focus varies. {Bourne,1995 }
Some symptoms of GAD that are listed on the anxiety network website include the following: feeling of unreality, breathing difficulties, hot or cold flushes, nausea, shortness of breath, fear of dying / losing control, sweating, dizziness, irritability and agitation, heart palpitations, chest pains, tingling sensations, trembling/ weakness, feelings of choking, feelings of going crazy, and sleeping difficulties{www.anxietynetwork.com cited June 10th 2007}.
Many people develop very poor coping mechanisms to decrease the high levels of anxiety, including smoking cigarettes, coffee, use of recreational drugs and alcohol. These coping mechanisms often exacerbate the already high levels of anxiety.

YOGA THERAPY PRACTISES

It would seem that yogic techniques have already been bought into the mainstream in the treatment of GAD. After researching various websites and journals, it seems there is a general agreement that good Nutrition, appropriate physical exercise, relaxation techniques, breathing techniques and finding your Spirituality or purpose in life are effective tools in the management and healing of GAD clients. Techniques borrowed from Yoga are already part of the mainstream treatments for this disorder, along with Cognitive behavioural therapy and medication.
As the severity and presentation will vary from client to client, various yoga therapy techniques could be implemented upon research into the clients own set of symptoms. But generally speaking, a therapy comprised of asana, pranayama, relaxation, meditation and self inquiry would offer a balanced program directed toward healing of the client on all levels of their being.

ASANA

Being in a state of prolonged anxiety, the para sympathetic and nervous system would need to be attended to, along with the state of the Adrenal glands and the digestive system. A rejuvenating sequence would seem appropriate, but may need to come at a later stage when the client has moved from being totally in their minds, to being aware of the body and its sensations , and able to focus the mind on the body in the asana and stay in a supported relaxed position for sometime.
In readiness for this an introduction into mindfulness and awareness would seem appropriate, and a few simple strategies that could be implemented in daily life may be helpful. To start with we may need to stay very simple and avoid too much yogic philosophy and “thinking stuff”. We need to use tools that reengage the mind, with the body, in the moment,- perhaps using simple daily tasks; rather than introducing a program that in itself may cause more worry and anxiety .{ie:worry about ability to be able to follow the program, worry over not doing it.}
Therefore we could question the client on daily activities and what they enjoy doing, then starting with a simple daily task such as:

# When you are washing the dishes in the morning, lets really do the dishes….lets feel the sensations of the water on the skin, lets stay present with the task and as soon as you notice you are worrying or gone onto auto pilot bring your mind back to the task at hand, learning to be gentle and non judgemental when we have found the mind wandering back to a worry, and bringing the mind back to the task at hand, the different textures of the crockery, the colour, the size of the bubbles, just even for one moment staying present with the task at hand .Depending on the outcome , we could gradually try to increase the moments of awareness, especially with tasks that could more easily than others become relaxing { bathing, showering, or walking to the shops or walking the dog, eating meals }. Even a moments reprieve from chronic worry, will reintroduce the feeling of well being that is so drastically needed in dealing with this disorder.

# finding the right balance and guiding the client in physical asana practise will be extremely helpful, maybe using soothing music and aromatherapy oils to create an atmosphere conducive to relaxation. Constant worry leaves the mind fragile and the muscles constantly tensed, so gentle seated and lying postures may work well to start, of course some clients may be so wired they cant even sit, in which case we may need to work with the strengthening standing poses such as the warrior sequences. Empowering, chest opening and grounding they encourage us to open and stand firm in our life, they encourage our connection to both the Earth and our spiritual being.
We often notice people who worry excessively carry the world on there shoulders, so introducing gentle standing shoulder rolls and synchronised breathing would release pent up energies, as could Uttanasana done as a slow rollup-roll down sequence, with attention to letting go and the movement of the breath.
Generally we are looking for postures that will encourage emotional and physical release on a level that will be appropriate for the client- as this is a chronic anxiety disorder it has probably been going on for some time and it will take time to integrate the life changing skills that yoga offers. So, taking things slowly and remembering to stop and smell the roses.

# PRANAYAMA
As a skill to be used when symptoms of excessive worry become pronounced, and as a means to reenergise the pranayama Kosha , the nadis, the subtle nervous system and to lift depleted Prana levels. Already deep breathing techniques are being used in the treatment of GAD, as noted in E.J Bourne’s, “The anxiety and Phobia workbook”{1995,pg71}
“The Calming breathing exercise was adapted from the ancient discipline of yoga, it is a very efficient technique for achieving a deep state of relaxation quickly” and he goes on to describe Ujjaya Pranayama, with extended exhalations, extended inhalations and pauses between the breath.So, already we know we have a successful treatment on hand. Breath awareness and Pranayama practises would be the foundation of our therapy, the mind which rides on the breath will be immediately affected by Pranayama. Another practise that helps calm and settle the nervous system and thus quieten the mind is Nadi shodana Pranyama, or alternate nostril breathing, as this also requires movement of fingers, the mind must stay on the job, of course if this level of concentration brings difficulties, we can do a practise during relaxation where we don’t actively block the nostrils, just practise this Pranayama in the mind.
RELAXATION AND MEDITATION
Progressive muscle relaxation technique involves tensing and relaxing, in succession, sixteen different muscle groups of the body {Bourne,1995, pg 74}. If a person is so used to feeling anxious and uptight, all our coaxing and relaxation theories may serve no more than to make a client even more worried that they don’t know how to and therefore can never relax. This muscle relaxation exercise serves to allow the feeling of tensed muscles and the conscious letting go of the tension, thus relearning the feeling of relaxation, using this technique as an entry into the deeper practise of savasana or yoga nidra meditation may be useful. Of course, often after a yoga session, this letting go will spontaneously occur, and we should not underestimate the power of yogic techniques when used in a balanced holistic sequence to bring about profound changes to both mind and body.
Before Yoga Nidra is practised a Sankalpa or positive resolve is set by the client, in the case of GAD, a resolve of “just for this moment I will not worry”, or a conscious decision that peace of mind is important to your well being on all levels, and this time is especially for that, and not for other worries. Again depending on the nature of the client, we would have to find Sankalpas that resonate with the person, and help them to let go and find trust.
Hopefully, once a client became used to practising yoga nidra, we could use the practise to help release the stored emotions behind this disorder, we would have to be especially aware that this release is a possibility, as for some clients they may not be at all ready for such in-depth meditations.
For some clients, reciting a Mantra would be helpful. Sometimes keeping the mind occupied, especially with a meaningful phrase or healing Sanskrit mantra allows for deep relaxation and a much needed break from excessive thinking. Mantras such as OM, or RAM are calming and dispel fears, RAM especially brings down the divine healing force, and conquers worry, fear , anxiety and lack of faith.{Frawley,1999}. Using mantra at any time during the day when worrying became excessive is a helpful tool to shift the mind.
Many other guided visualisations of beautiful, calm places may be used to facilitate relaxation and for some clients perhaps constant instructions will be necessary to keep the mind engaged in the exercise so the necessary relaxation of the physical body can take place.
If a client has come to see you as a yoga therapist, it seems they must have made some commitment to wanting to implement change in their lives, recognising this and building on this foundation will help the client keep that commitment to self healing and growth. Where appropriate, we can introduce concepts such as the self, or the divine within us all, and gradually help to nurture a re -connection to their spiritual being, or the universal spiritual source.
. The most beautiful, but often forgotten truth, is that the peace and bliss of the heart are always with us, and even if we can help a client experience this connection for one second - when the mind stills and the heart speaks, it opens the entire being to a new knowledge, a new language and often that taste is enough to begin a personal transformation toward non separation, and embracing life as a divine gift, rather than something to be feared and controlled.
CONTRA-INDICATIONS
It seems that GAD contains an element of fear, we must be extremely careful to make sure our client’s boundaries are respected and that we move through the treatment at a pace that is in synch with our client. We must be sure to build trust and faith before leaping into therapies that may open cans of worms that the client or you as a therapist can’t adequately deal with.
Meditation of course starts to sharpen the mind, but with an unstable mind it can create a myriad of other problems, or if the patient is on medications adverse reactions may occur. Sometimes even the simple act of closing the eyes and being left with yourself is too much for a client. I would recommend moving slowly toward the silent, still types of meditation so as not to induce fear or experiences the client is not able to handle.
Touch, may also be an issue, some people may not be comfortable being touched and even though we know touch has potent healing qualities, be must be very careful that trust is established and we ask permission , always respecting boundaries.
If the client presents with GAD and depression, we would avoid forward bends and any practises that are overly internalising.
As a general rule, we must be very conscious of our own breathing patterns, as clients will often naturally fall into synch with the therapist. We must take care of our own grounding and centring, so we can maintain balance and not follow or take on our clients “stuff”.
Yoga therapy has a huge role to play in the future of mental health and well being, and as mental disorders seem to be a side effect of our fast paced modern society , a return to the knowledge and wisdom of the ancients firmly based in love and compassion can only help open the doors to healing .

REFERENCES
Bourne,E.J {1995}, The Anxiety and phobia workbook, New Harbinger publications,Oakland, CA.

Frawley,D{1999} Yoga and Ayurveda,Lotus press, Wisconsin

Morrison,J.M {1995} DSM1V made easy, Guilford press, New York